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AS BUILT SANITARY SYSTEM REPORT
OWNER r i G r^ 177 r e
ADDRESS
SUBDIVISION / CSMJ LOT
SECTION- T~N-R~W, Town of J~/R•~~~i e
ST. CROIX COUNTY, WISCONSIN 0 '50 ,l II; - 1-0 -00 y ~ of 0, WA.A-
1711 PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~Oa
c~
INDICATE NORTH ARROW
G
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r r,
BENCHMARK: _
ct
ALTERNATE BM:
ti
SEPTIC T PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity: Setback from: Wel use X l~_~J i _ ~
o Other
Pump: Manufacturer
Model#Size
Float seperation
Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /
Length Number of trenches
Distance & Direction to nearest prop. line: Setback from: well:/ 4/40 use-,Z~ Other
ELEVATIONS
Building Sewer
12 1 ~j ST Inlet: , ~ ST outlet:
, 6 1
PC inlet PC bottom
Pump Off Header/Manifold Bottom of system
3 _
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
~WisconsinDepartment of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299080
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
GERMAIN, ERIC L STAR PRAIRIE
Parcel Tax 8-
CST BM Elev.: Insp. BM Elev.: BM Description: 038-
•~O //2'p. b , 1113-80-000
TANK INFORMATION LEVATION DATA A970 400
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark Q , ; pQ
Dosing
Aeration Bldg. Sewer 10 '
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet S' ov-K 3 '
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic y NA Dt Bottom
Dosing NA Header / Man. q 9?- 9
Aeration NA Dist. Pipe
Holding Bot. System Ct 51 i" 6 9 '
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 11*1V_W 6"j. Al
Model Number GPM
TDH Lift Lricti System TDH Ft
Head
Forcemain L gth Did. f Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS -5' I DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type of /Kur-r' CHAMBER Mode Number:
System: Aza P? yS ` OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed /Trench Edges ,gyp Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 28.31.18.482A,SE,SE 1093 192ND AVENUE
13 fi~, (0 ; 6-p , X --k~ 1j_G_k,_) 00
zz, A"t
Plan revision required? ❑ Yes ['No
Use other side for additional information.
SBD-6710 (R 05/91) Date I s ctor's Signature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
J
t t
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Wisconsin In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI W707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County _ 11
than 8 112 x 11 inches in size. (Vank
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ggopv O
❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
, ,'C G r,r.n _ 1/4 1/4, S T , N, R /Or E (or
Property Owner's Mailing Address /A Lot Number Block Number
/VC.[/ 'sue
City, State Zip Cod Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ qty Nearest Road
❑ VIl age
Public 1 or 2 Family Dwellin - No. of bedrooms own OF a.- ✓
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. flew 2_ ❑ Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an
ystem System_____________ Tank Only ______________Existing System Existing System
_
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 eepage Bed 21 ❑ Mound 30E] Specify Type 410 Holding Tank
110 Seepage Trench 22E] In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Propos d sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
s
67, 43 Feet eet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass App.
New Existin structed
Septic Tank or Holding Tank Tanks Tanks Q ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El ❑ El 11 El El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for install tion of the o ite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Si a e: o Stamp MP/MPRSW No.: Business Phone Number:
ess (Stregy, G, Zi Code): ~
Plumber's did 6
IX. COUNTY / DEPARTMENT USE ONLY
Lo~ rmit Fee (Includes Groundwater ate Issued Iss ing Agent Signature (No Stamps)
❑ Disapproved Sanitary Pe
~y Surcharge Fee)
Approved ❑ Owner Given Initial- 4WL
Adverse Determination 1/0-PI-7
X. CONDITIONS OF APPROVAL/ REASO S FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, rkanber '
INSTRUCTIONS
1 _ A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in riame, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
PLOT PLAN
,PROJECT Eric Germain ADDRESS 1097 192nd Ave New Richmond Wi 54017
SE 1/4 SE 1/4S 28 /T 31 N/R 18 W TOWN Star Prairie COUNTYST.CROIX
9/20/97 BEDROOM 3
MPRS Shaun Bird 3532: DATE
CONVENTIONAL X040( IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
MOUND
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 BED SIZE 18'X 50'
BENCHMARK V.R.P. Top of White Stake ASSUME ELEVATION 100'
❑ BOREHOLE O WELL +H.R.P. Same as Benchmark
SYSTEM ELEVATION 96.8
192nd Ave
VENT
12" GRADE
TYPAR COVERING
rivewa
12" 3'6' (D 3' T (D 3'
R SEWER R K
12' 18' Garage Pro 3 Bedroom
Double Wide
900'
30'
T
7
'D
a
3 40'
*B. B-5 40' B-2
200'
10'
Rep A
3'
10% \ 18' X 50' Bed
Slope B-3 \
30' \ \
Vent
B-1
14
B-4 40'
PLOT PLAN
PROJECT Eric Germain ADDRESS 1097 192nd Ave New Richmond Wi 54017
SE 1/4 SE 1/4s 28 /T31,/,4 N/R) 8 W TOWN Star Prairie COUNTYST. CROIX
9/20/97 BEDROOM 3
MPRS Shaun Bird 3532 DATE
CONVENTIONAL X)00( IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 BED SIZE 18'X 50'
BENCHMARK V.R.P. Top of White Stake ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 96.8
192nd Ave
VENT
12" GRADE
TYPAR COVERING
k.Veway
1'9 3' 6' (D 3' 3' 3'
i SEWER R K
12' 18 Garage Pro 3 Bedroom
Double Wide
00'
30'
T
y
40'
200' *B B-5 40' B-2
10'
Rep A
3 '
10% 18' X 50' Bed
Slope B-3
30' \
Vent
-1
B-4 40'
Wisconsin, Department of Commerce
Division, of Safety and Buildings a i AND SITE EVALUATION Page
Bureau of Integrated Services ^ AWN" h s. ILHR 83.09, Wis. Adm. Code
t
Attach complete site plan on paper than AWN" in'lize;Plan must county
include, but not limited to: vertical zontal reference point (BMJ.,; a lion and 6v
'to "
percent slope, scale or dimensions, stance tl) nearest road. Parcel I.D. #
' j
ST CROIX
APPLICANT INFORMATION se G do Reviewed by Date ING Personal information you provide may be or Ory purposes ( . s. 15.04 (1) (m)).
Property Owner] Z Property Location
1/4 ~t' 1/4,S ! T N,R E (or) W
GovL Lot
y- i G fj 7 '%y+k
Property Owner's Mailing Address Lot # Block#1 Subd. Name or CSM#
,z~
City tats . Zip Code Phone Number ❑ qty El Village Town Nearest Road
/
New Construction Use: Wesidential / Number of bedrooms Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow grd Recommended design loading rate L bed. gpd* ,/(trench. gP&*
Absorption area required bed, ft2. )50_ ft2 Maxi mum d 'gn loading rate ---jLbed, 9Pd/f~ - trench, 9pd/fl2
Recommended infiltration surface elevations r
Z 61 ft (as referred to site plan benchmark)
Additional desigrVsite considerations
Parent material ~J Flood plain elevation, if applicable 46 ft
S = Suitable for system Conventional Mound In-Ground Pressure AT Grade System in Fill Holding Tank
U = unsuitable for system ❑ U E~S ❑ U ❑ u KS ❑ U ❑ S ❑ S Ax
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/112
13 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
0- a 2 s r"- ,
/ S D / )
Ground 3
2Y4
Depth to
limiting
factor
Remarks:
Boling # o?~-
13
~Ground
Depth to
limiting
ccsp
?l/`bin. Remarks:
Name (Please Print) Signatu Telephone No.
Jr. 5-a6 -
Date CST Number
ERTY OWNERy'i G ('~/nCl,Cn^' SOIL DESCRIPTION REPORT
Page Hof
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~ptft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
13 I 08 dlal2 s eS 0,,4,
Ground i ® ~v~ I S -fj
elev.
R.
AR
S 7
Depth to
limiting
>f~d
Remarks:
Boring #
d
Ground
Depth to
limiting
r
7K Remarks:
3 Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. p Bed , Trench
Boring # 0 r r+^' S : t
YY'
a Sao a f
o Ds ;
Ground
Depth to
limiting
f
~'=in. Remarks:
oring #
Ground
j elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R. 07/96)
k Soil Test Plot Plan
Project Name Eric and Michelle Germain Byro rd Jr.
c
Address 1097 192nd Ave
New Richmond Wi 54017 CS #3479
Lot Subdivision Date 7/20/97
SE 1/4SE 1/4528 T 31 N/R18 W Township Star Prairie
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Top of White Stake
System Elevation 96.8/94.6 * H R P Same as Benchmark
192nd Ave
900'
0
c~
C"
a
c~
200' *B B-5 40' B-2
10'
Rep A Pri A
30'
10% -3
Slope
30'
0' -1
B-4
FILED 2
. s
AUG 2 7 1997 ►
KATHLEEN H. WALSH 3
8 Repislera(Deeds
St.c~oafC4w1
ti
564300
CERTIFIED SURVEY MAP
Located in part of the Southeast Quarter of the Southeast Quarter of Section 28, Township 31 North, Range dJ
18 West, Town of Star Prairie, St. Croix County, Wisconsin.
• EAST 114 CORNER
Prepared for and at the request of:
OWNER: TOTAL AREA LOT 2, l SEC. 28-31-18
102,703 SO. FT. (ALUM. CO. MON.)
Eric J. and Michele T. Germain 2.36 ACRES i
1097 192nd Avenue
New Richmond, WI 54017 AREA EXL UD. R.O.W.:
Drafted by. Kristi A. Eylandt 88,J181 SO. FT. i I 1
LEGEND 2.03 CRES
ib. County Section Corner Monument 133'111
MAP
of Record CERTIFIED SURVEY
• Set 1" x 24" Iron Pipe weighing
DOC_ NO. 358851 ICI i% t
a minimum of 1.13 pounds per Io l~
linear foot. VOLUME 3 PAGE 835 ill 'I
O Found 1" Iron Pipe NORTH LINE OF THE EAST 1 2 OF , IIN 1
M= Measured As THE SE 1/4 OF THE SE 1/4
R= Recorded As e j ~1-+^I
N 192nd A ve192ND AVENUE
C
C --S 88'59'54" E 661.21'
- 331
>1 0 ° 295.84'= J I L
C L
N _-I-S88'50'50-Ei :661.25'--
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_ o I \ 0 760, 493 SO. FT. ► 3 $ °
V) 0 -75
m •C Zi w ai 17.46 ACRES U 1
o N N Jj W N AREA EXCLUD, R. O. W.: N
a o °i W o f 742,722 SO. FT. i o j z l
I I o I ~ I
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86 Z) N N A WtS
J ci AUG 2 7 1997 ► 00
KATH
Ot Z Z ~Okisfer of Deeds
t.lil` LEEN H. WALSH
SL Croix Co., WI
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3.T.V313 I, HED S , HOXSAHnS
STcc -(oO
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-
Owner of property
Location of property: -_1/4_1/4, Section,2', T3N-R/ W
Township Mailing address
Address of site
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property lZ-/
Total size of property -~2 ':2
Total size of parcel
Date parcel was created v2 9
Are all corners and lot lines identifiable? -Yes No
Is this property being developed fo (spec house)? Yes ~ No
Volume ,,'and Page Number eo O as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true +,o the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 55,2, , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
tY~~ o e~ ?~f the County Register of Deeds as Document No.
Signature o Applicant Co-Applicant
Da e of Signature Date of Signature
r ~'e r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
e~ l~2 f yea
OWNER/BUYER
MAILING ADDRESS 1/S
PROPERTY ADDRESS
(location of septic system) Please obtain the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 5~-- 1/4, Section , T_N-R2LW
TOWN OF , / / ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
AGE SLOT NUMBER
VOL
CERTIFIED SURVEY MAP6 6"`s0'9
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
VWe, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office '
Government Center
1101 Carmichael Road 11/93
Hudson, WI 54016
r 559369 STATE BAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO. YOl 138 PACED 8
REuISTE~~) c 11'E
S7 CROIX C0., Wi
Louella J Rivard, n/k/a Louella J. Arnold, &,edk>rlAMIQ
a single person,
'MAY, 14 1997
conveys and warrants to Eric J Germain and fat 11:45 A M
Michele T. Germain, husband and wife, as -K.* -4 L).hi.
survivorship marital property,
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in 4 t C r o i x County,
State of Wisconsin: k-
038-1113-80
PARCEL IDENTIFICATION NUMBER
E1/2 of SE1/4 of SE1/4 of Section 28-31-18.
TRAN%FER
~t4+4 ~j D
FEE
This is not homestead property.
Xx~xR (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
Dated this day of May A.D., 19 97
(SEAL) Z2AAJja (SEAL)
•Louella Rivard, n/k/a Louella J
Arnold
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Louella J. Rivard, n/k/a State of Wisconsin,
.
Louella J. Arnold
County. ss
nwhPntiratPrl this Off-~ rlavnf Mav 19 97 Personallv came before me this day of